Patient’s View on - “Low-protein diet with personalized support in advanced chronic kidney disease: association with disease progression, dialysis delay, and mortality” - Takamasa Iwakura

Q: Why is dietary modification presented as acceptable for patients with advanced CKD?

Dietary modification can be more acceptable than adding another medication because it lets patients feel involved in decisions about their treatment. It also directly relates to daily life, making quality-of-life considerations central to adherence.

Q: What baseline treatment issues are emphasized in the discussion?

The discussion highlights relatively low use of RAAS inhibitors and blood pressure that was above recommended targets at enrollment. It notes that these factors suggest underlying optimization was not fully achieved before nephrology referral.

Q: What outcome improvement is highlighted for the low-protein diet group?

The discussion reports an annual eGFR slope improvement of −1.76 ml/min/1.73 m² per year in the low-protein diet group compared with controls. It also suggests that improved blood-pressure control may have reduced intraglomerular pressure and contributed to kidney function changes.

Sep 30, 2026

Uploaded by Ophelia

A patient-focused discussion reviews an observational study in advanced chronic kidney disease evaluating a moderately restricted low-protein diet with personalized support and a weekly unrestricted meal. The account highlights patient acceptability, practical adherence, and the relevance of quality-of-life concerns when diet directly reshapes daily living. It also examines baseline treatment limitations, especially low RAAS inhibitor use and suboptimal blood-pressure control, and interprets improvements in kidney outcomes alongside possible blood-pressure–linked intraglomerular pressure effects and timing of SGLT2 inhibitor adoption.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Patient’s view

Low-protein diet feasibility and adherence

Baseline patient risk and treatment optimization

Blood pressure control and RAAS inhibitor use

Potential roles of SGLT2 inhibitors

eGFR slope changes

Clinical Kidney Journal, 2025, vol. 19, no. 1, sfaf385 [https:/doi.org/10.1093/ckj/sfaf385](https:/doi.org/10.1093/ckj/sfaf385) Advance Access Publication Date: 9 December 2025 Patient’s View PATIENT’S VIEW Patient’s view on: “Low-protein diet with personalized support in advanced chronic kidney disease: association with disease progression, dialysis delay, and mortality” Takamasa Iwakura 1 ,2 1 Preventive Medicine for Severe Progression of Lifestyle-Related Diseases, Hamamatsu University School of Medicine, Hamamatsu, Japan and 2 First department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Hamamatsu, Japan Correspondence to: Takamasa Iwakura; E-mail: [tkms0421@hama-med.ac.jp](tkms0421@hama-med.ac.jp) This observational study from Bologna, Italy, evaluating a moderately restricted low-protein diet (LPD) in patients with advanced CKD, was highly engaging from a patient representative’s perspective. It was particularly meaningful that the authors focused not on adding another medication, but on nutritional management, an area where patients can actively participate in their care. Patients with CKD often take multiple medications and maybe reluctant to add yet another drug. In contrast, dietary modification can be more acceptable because it allows individuals to feel involved in their treatment decisions. At the same time, dietary restrictions directly affect daily life, and therefore quality of life (QOL) concerns are just as important as adherence. Historically, strict protein restriction has suffered from poor adherence and significant lifestyle burden [1] . In this context, the moderate restriction examined in this study (0.6–0.7 g/kg/day), combined with personalized support and a weekly unrestricted meal, seems far more feasible. The high acceptance (96%) and moderate adherence (about 60%) underscore the practicality of such an approach. Several aspects of the study population are noteworthy. The participants had relatively high-risk characteristics, including a median proteinuria of 0.94 g per 24 hours, hypertension in nearly 87%, and diabetes in 43%, yet the use of renin–angiotensin– aldosterone system (RAAS) inhibitors, a cornerstone of CKD treatment, was unexpectedly low at ∼30%. This finding could not be explained by hyperkalemia or metabolic acidosis, and the use of potassium binders was also limited. Because CKD progresses slowly, it is critically important to optimize fundamental therapeutic measures before patients reach advanced stages. These measures include adequate blood pressure control and appropriate use of RAAS inhibitors, and early intervention is expected to maximize the potential for slowing kidney function decline. In this study, conducted between 2021 and 2023, the mean systolic blood pressure at enrollment was well above the KDIGO 2021 recommended target of <120 mmHg [2], suggesting that treatment may not have been fully optimized before nephrology referral. In addition, many older patients may have found it difficult to reach lower blood pressure targets due to medication tolerability issues. Differences in recommended blood pressure targets for older adults across international guidelines may also help explain why blood pressure tended to remain higher in this cohort. Furthermore, the low use of RAAS inhibitors may have contributed to suboptimal blood pressure control. At the last visit, blood pressure was still not sufficiently controlled, and discontinuation of RAAS inhibitors was relatively common. Given these circumstances, the effects ofthe LPD should be interpreted in the context of suboptimal baseline management. Even so, Received: 5.12.2025; accepted: 5.12.2025 © The Author(s) 2025 . Published by Oxford University Press on behalf of the ERA. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ([https://creativecommons.org/licenses/by/4.0/](https://creativecommons.org/licenses/by/4.

FAQs

Why is dietary modification presented as acceptable for patients with advanced CKD?

Dietary modification can be more acceptable than adding another medication because it lets patients feel involved in decisions about their treatment. It also directly relates to daily life, making quality-of-life considerations central to adherence.

What baseline treatment issues are emphasized in the discussion?

The discussion highlights relatively low use of RAAS inhibitors and blood pressure that was above recommended targets at enrollment. It notes that these factors suggest underlying optimization was not fully achieved before nephrology referral.

What outcome improvement is highlighted for the low-protein diet group?

The discussion reports an annual eGFR slope improvement of −1.76 ml/min/1.73 m² per year in the low-protein diet group compared with controls. It also suggests that improved blood-pressure control may have reduced intraglomerular pressure and contributed to kidney function changes.

Sep 30, 2026

Uploaded by Ophelia